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THE TREATMENT OF MIGRAINE-ABORTIVE TREATMENT
For mild, infrequent migraine, simple analgesics, like aspirin and acetaminophen, may occasionally effectively and safely abort the pain, but analgesics should not be taken daily for headaches. Sometimes, a sedative or a sleeping pill can help the victim sleep through the several hours of discomfort.
Unfortunately, analgesics, even the narcotic type given by injection, are not always effective in relieving migraine, and many people cannot afford the luxury of sleeping. Recently we suggested sleeping for a housewife who has occasional migraine. She quickly responded, “How can you expect me to take the afternoon off when I have three screaming kids? They’ll destroy my house!”
Although these drugs are of value in some circumstances, most patients with migraine need special medications that exert some control of blood vessels. Various forms of the so-called vasoactive medications (medications that affect blood vessels) can be used in either the abortive approach (to stop an attack) or the preventive approach (to prevent the onset of an attack).
Ergotamine is the most commonly employed specific agent to abort a migraine. Ergotamine is often combined with caffeine, sedatives, and antinauseants. Ergotamine can be administered in ordinary tablet form, inserted in the rectum as a suppository, used as a tablet that dissolves under the tongue, given as an inhalant to be breathed into the lungs, or injected. To be most effective, the ergotamine preparations must be taken at the very first sign of migraine. In the case of classical migraine, this means during the preheadache phase. This requires that the drug be constantly available. The unpleasant preheadache phase of classical migraine, which announces that a headache will follow, is, naturally, not prevented by ergotamine since the drug’s major effect is to combat the painful dilation of the blood vessels and not the constriction associated with the preheadache phase. This is a serious shortcoming of the abortive medications because it is the preheadache phase and its potential permanent neurological symptoms that pose the greatest medical risk.
There is some evidence to suggest that vasoconstricting medications, when given during the preheadache phase, may actually impose an additional risk toward stroke. We advise our patients with classic migraine either not to take vasoconstrictive drugs at all or to delay their use until the preheadache phase has terminated. While this reduces the potential effectiveness of the drug by delaying its entrance into the bloodstream, we believe that the reduction in therapeutic effectiveness is worth the enhanced safety that this delay affords.
The major failings of this widely used and frequently successful abortive approach include the need to have the medication available at all times, the inability to prevent the preheadache symptoms, and the potential unwanted reactions associated with ergotamine’s use.
Usually a medication capable of producing beneficial effects can also be responsible for side reactions, some equally as troublesome as the primary complaint. Were you to read the list of adverse and potentially dangerous side effects of simple aspirin, you might shudder to think that such a drug could be used without a prescription or medical supervision. A basic principle governing the use of any medication is that the possible benefits must be carefully weighed against the possible risks.
Fortunately, most of the side reactions associated with the medications used for migraine are relatively mild and usually disappear when the drug is withdrawn. Nevertheless, ergotamine should not be taken by people with blood vessel disorders, such as coronary artery disease and high blood pressure, or with significantly impaired liver or kidney function, or during pregnancy. The reason for abstaining during pregnancy is that ergotamine may directly affect the uterus and its blood vessels.
The most common adverse reactions associated with ergotamine are nausea and vomiting, often symptoms of the migraine itself. Other adverse effects include leg cramps, numbness and tingling of the fingers and toes, chest pain, abnormal heart rate, and itching and swelling of extremities. These drugs can be given safely only once or twice a week, and they are not recommended when migraine occurs more frequently. When these drugs are taken regularly, dangerous narrowing of blood vessels may occur. Rebound widening of blood vessels often develops when the medication’s effect wears off. Taking more medication will improve the rebound headache, but a dangerous cycle of dependency can lead to serious consequences.
The unwanted effects of ergotamine, including severe constriction of arteries, may be intensified with fever or significant infection. Patients taking ergotamine should either reduce their dosage or avoid the use of this drug during such episodes.
The following are some of the preparations containing ergot derivatives used in the abortive approach to treatment: Cafergot (tablet or suppository form), Ergomar and Ergostat (under the tongueЂ”sublingual form), Ergotamine Medihaler (inhalant), Migral (tablet form), and Wigraine (tablet or suppository form).
In Canada, ergotamine is found in many of the same preparations as in the United States. In addition, a Canadian preparation available in capsule form, called Gravergol, contains ergotamine, an antinauseant (dimenhydrinate) and caffeine. Dimenhydrinate (Gravol in Canada, Dramamine in the United States) is also available alone as an antinauseant.
Midrin is a combination tablet (vasoactive, analgesic, and sedative substance) also used for abortive relief of migraine. The active antimigraine agent in this product is isometheptene mucate and is not marketed by itself, but only in combination. Although isometheptene may cause some of the same side reactions as ergotamine and has many of the same precautionary restrictions, it is our experience that it is usually well tolerated by most people for
mild-to-moderate migraine. Its effectiveness is sometimes enhanced by the simultaneous administration of two aspirin.
Pain Relief/Muscle Relaxantcontrol of nausea. They may exert control over pain in a way quite independent of its other effects. We have found that chlorpromazine (Thorazine), which has both tranquilizing and antinauseant effects, can be very helpful in some patients.
The abortive drugs are used to treat an individual attack. Combinations of analgesics, sedatives, antinauseants, and specific antimigraine drugs are sometimes necessary.
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